HEALTH HISTORY QUESTIONNAIRE Healing Arts of Memphis 1541 Overton Park Ave. (Rear) Memphis, TN 38112 901 726 1485 Name Date Street City ST Zip Home Phone Cell Email Age Date of Birth Male Female HT WT Occupation Referred by Emergency Contact Relation to Emergency Contact Phone What kind of treatments have you tried? (Circle all that apply.) Acupuncture Chiropractor Homeopathy Massage Naturopathy Physical Therapy Western Herbs Chinese Herbs Family Physician Date of Last Physical: Main problem that you would like to resolve/when did symptoms first appear? Have you ever received a diagnosis for this problem? If so, what was the diagnosis and who made the diagnosis?
Healing Arts of Memphis Health History Questionnaire, page 2 Secondary complaint with which you would like assistance Current Infectious Diseases: (Circle all that apply.) AIDS Flu Hepatitis {A, B, C, D} Tuberculosis Autoimmune Disorders: Cancer Hospitalizations / Surgeries and dates: 1. 2. 3. Significant Physical / Mental Traumas: Auto accidents, falls, stressful events: 1. 2. 3. Please list any areas of your life that you would describe as stressful. If one is no stress and 10 is extreme stress, please highlight or circle the number that best reflects the level of stress you are experiencing. Stress of Main complaint 1 2 3 4 5 6 7 8 9 10 2. 1 2 3 4 5 6 7 8 9 10 3. 1 2 3 4 5 6 7 8 9 10 4. 1 2 3 4 5 6 7 8 9 10 5. 1 2 3 4 5 6 7 8 9 10 Do you have pets? No Yes If yes, what type? Allergies (Drugs, chemicals, metals and foods):
Healing Arts of Memphis Health History Questionnaire, page 3 Hobbies: Family Medical History (Circle all that apply.): Asthma Allergies Arthritis Cancer Dementia Depression Diabetes Heart Disease High Blood Pressure Thyroid Stroke Other Do you have a regular exercise program? No Yes If yes, please describe Medicines taken within the last 1 week (vitamins, herbs, prescriptions) 1. 6. 2. 7. 3. 8. 4. 9. 5. 10.. Diet Do you currently follow any type of special diet: (Atkins Diet, Gluten Free, Paleolithic, South Beach Diet Vegetarian, Vegan, Other avoid certain foods, lactose intolerant)? Do you eat meals at regular times? Food Cravings No Yes Salty Sweets Fats Blood Type O A B AB Other Please list what you ate yesterday? Breakfast Lunch Dinner Snacks Do you drink coffee? Yes No If yes, how many cups per day perr week?
Healing Arts of Memphis Health History Questionnaire, page 4 Do you drink soft drinks? No Yes If Yes, how many per day per week Do you like to sip water or are you inclined to drink a full glass of water? How much water do you drink on a daily basis? How many alcoholic beverages do you drink per week? Cardiovascular (Circle all that apply.) Blood clots Chest pain Cold hands or feet Difficulty in breathing Dizziness Edema in ankles High Blood pressure Irregular heart beat Heart murmur Low Blood Pressure Palpitations Phlebitis Varicose veins or spider veins Bleed or Bruise easily Rheumatic fever Angina Gastrointestinal (Circle all that apply.) Bad breath Bleeding Gums Acid Reflux Abdominal pain / cramping Gas Belching Bloating / Edema Excessive Appetite Food stagnation Indigestion Slow Digestion Poor Appetite Vomiting Bowel Patterns Do you have a bowel movement every day that feels complete? Yes No If no how many bowel movements do you typically have one a weekly basis? (Circle all that apply.) Blood in stools Constipation Diverticulitis Hemorrhoids Colitis IBS / Crohn s Diarrhea Laxative use Loose stools Strong odor General Body Metabolism Are you normally comfortable temperature-wise in your body? Yes No If no, do you experience the following?(circle all that apply.)
Healing Arts of Memphis Health History Questionnaire, page 5 Chills Fever Fatigue Weight gain Weight loss Generally feel hot Crave hot drinks? Crave Cold Drinks? Room Temperature Drinks? Head, Eyes, Ears, Nose and Throat? Headaches / Migraines No Yes If yes how often When did you experience last headache / migraine? On a scale of 1-10 where 1 is no pain and 10 is extreme pain Highlight appropriate pain level 1 2 3 4 5 6 7 8 9 10 Sinus Infections: No Yes If yes, how often On a scale of 1-10 where 1 is no pain and 10 is extreme discomfort, Highlight or circle appropriate discomfort 1 2 3 4 5 6 7 8 9 10 Do you normally take antibiotics for sinus infections? Eyes (Circle all that apply.) Blurred Vision Cataracts Color Blindness Eye Strain Eye Pain Floaters Glasses/Contacts Glaucoma Night blindness Ear infections Ear wax Hearing loss Ringing in ears Facial Pain Nose Bleeds Sinus drainage Jaw clenching Tooth pain Sores on tongue Recurrent sore throats Musculoskeletal (Circle all that apply.) Back Pain: Low Middle Upper Bursitis Carpal Tunnel Foot or ankle pain Hip pain Knee Pain Muscle weakness Muscle spasms Neck pain Rotary Cuff Sciatica Sprains/strains Hand or wrist pain Arthritis Rheumatoid Arthritis Hernia
Healing Arts of Memphis Health History Questionnaire, page 6 Neurological Concussions Loss of Memory Dizziness Loss of Balance Poor coordination Areas of numbness Chronic Fatigue Sweat easily Night sweats Tremors Numbness Easily susceptible to stress Psychological ADD / ADHD Panic attacks PTSD Obsessive Tendencies Phobias Sexual abuse Do you have a therapist? No Yes If yes, are you currently seeing therapist on a regular basis? No Yes Have you considered suicide in the last 6 months? Have you attempted suicide in the last 3 years? No Yes No Yes On a daily basis, please highlight any of the emotions that you currently experiencing Low High Sense of well being 1 2 3 4 5 6 7 8 9 10 Sense of gratefulness 1 2 3 4 5 6 7 8 9 10 Sense of joy, happiness 1 2 3 4 5 6 7 8 9 10 Sense of burden of responsibility 1 2 3 4 5 6 7 8 9 10 Sense of underlying frustration 1 2 3 4 5 6 7 8 9 10 Sense of anger 1 2 3 4 5 6 7 8 9 10 Sense of depression 1 2 3 4 5 6 7 8 9 10 Sense of sadness or grief 1 2 3 4 5 6 7 8 9 10 Sense of worry, anxiety, nervousness 1 2 3 4 5 6 7 8 9 10 Sense of fear 1 2 3 4 5 6 7 8 9 10 Energy level 1 2 3 4 5 6 7 8 9 10 Respiratory Do You smoke cigarettes? Yes No
Healing Arts of Memphis Health History Questionnaire, page 7 Do You smoke marijuana? Yes No If yes, for how long? How many per day? Would you describe yourself as a shallow or a deep breather? Asthma Bronchitis Blood in sputum Bronchitis Chest pain Pneumonia Difficulty with inhalation / exhalation Chest tightness Dry Cough Productive cough, white / yellow phlegm Skin and Hair Acne Dandruff Dermatitis Eczema Hair loss Hives Itching Moles Psoriasis Rashes Toe nail fungus Ulcerations Rosacea Any other skin or hair problem? Sleep Patterns What time do you normally retire? Do you fall asleep easily? Yes No If no, how long does it normally take to fall asleep? When asleep, do you stay asleep or do you wake up during the night? When you awaken do you feel rested or do you find that you are tired? Do you feel like you get enough sleep? Yes No Dream-Disturbed Sleep No Yes Nightmares No Yes If yes, How often? For how Long? Do you have sleep apnea? No Yes Do you snore? No Yes Uro-Genital History of UTI s No Yes If yes, do you normally use Antibiotics No Yes Do you normally get up at least once per night to urinate History of Kidney infections No Yes No Yes
Healing Arts of Memphis Health History Questionnaire, page 8 History of Kidney stones Do you urinate more than 5 times a day? No Yes No Yes (Circle all that apply.) Blood in urine Cystitis Decrease in flow Pain with urination Urgency to urinate Unable to hold urine Male Reproducitve Excessive libido Impotence Low libido Prostate swelling Reproductive & Gynecologic Are you pregnant Is it possible that you are pregnant Do you practice birth control No Yes No Yes No Yes If Yes what type How long Number of pregnancies Live Births Miscarriages Abortions Premature births Ovulation Day Is Ovulation Painful Mid Cycle spotting No Yes No Yes Premenstrual symptoms No Yes If yes, circle all that apply. Breast tenderness Mood swings irritability Food cravings Weight gain What day do you begin to experience premenstrual symptoms? Period Age of first menses Duration of Menses Time between menses Painful periods No Yes If yes, which day? Day 1 Day 2 Day 3! Irregular periods Clots No Yes If yes, amount? A few A lot Size? dime size quarter size half dollar size
Healing Arts of Memphis Health History Questionnaire, page 9 Character of blood Day 1 Very light Brown Red Purple Very dark Day 2 Very light Brown Red Purple Very dark Day 3 Very light Brown Red Purple Very dark Day 4 Very light Brown Red Purple Very dark Day 5 + Very light Brown Red Purple Very dark Volume of Blood Day 1 Scanty Normal Heavy Day 2 Scanty Normal Heavy Day 3 Scanty Normal Heavy Day 4 Scanty Normal Heavy Day 5 + Scanty Normal Heavy Reproductive Pathology Date of Last PAP Negative Positive (Circle all that apply.) Breast lumps Fibrocystic Breast Disease Endometriosis Polycystic ovarian disease Vaginal Dryness Vaginal soreness Hysterectomy Ovarian cysts Anemia Uterine Fibroids No Yes if yes number and size Vaginal Discharge No Yes If yes, Clear White Yellow Menopausal Premenopausal Age that periods became irregular Menopausal Age Date of last bone scan Are you losing currently losing bone mass? No Yes Hot Flashes? No Yes If yes, Mild Moderate Severe